Abuse, Neglect and Post-Traumatic StressSaturday, May 7, 2011
Today’s post is another excerpt from “Best Weight: A Practical Guide to Office-Based Weight Management“, recently published by the Canadian Obesity Network.
This guide is meant for health professionals dealing with obese clients and is NOT a self-management tool or weight-loss program. However, I assume that even general readers may find some of this material of interest.
ABUSE, NEGLECT AND POST-TRAUMATIC STRESS
Childhood maltreatment or adverse experiences in five domains (emotional abuse, physical abuse, sexual abuse, emotional neglect and physical neglect) have been reported as highly prevalent in patients with binge-eating syndrome. In one study, 83% of patients with binge eating reported some form of childhood maltreatment: 59% reported emotional abuse, 36% reported physical abuse, 30% reported sexual abuse, 69% reported emotional neglect, and 49% reported physical neglect.
Maltreatment, notably emotional abuse and neglect, is significantly associated with depression and low self-esteem, but its relationship to weight, the onset of obesity or to other obesity-related features is less straightforward. Weight may be used by patients (consciously or unconsciously) as a way to push away the world or intimacy.
Post-traumatic stress disorder occurs in a subgroup of individuals exposed to a severe life-threatening trauma. The core set of symptoms are: intrusive re-experiencing, avoidance and arousal. Co-morbid substance abuse and mood and anxiety disorders are common. Trauma-exposed individuals are more likely to engage in behaviours that present a health risk and are more likely to report physical symptoms and functional impairment. A high prevalence of overweight and obesity is found in patients with post-traumatic stress disorder.
It is important to monitor patients with a history of abuse for recurrence of emotions or memories as they lose weight. Before initiating a weight-loss strategy, the possibility of weight-loss distress should be discussed with the patient. This is not an uncommon occurrence and the patient should know you are willing to discuss it with them.
© Copyright 2010 by Dr. Arya M. Sharma and Dr. Yoni Freedhoff. All rights reserved.
The opinions in this book are those of the authors and do not represent those of the Canadian Obesity Network.
Members of the Canadian Obesity Network can download Best Weight for free.
Best Weight is also available at Amazon and Barnes & Nobles (part of the proceeds from all sales go to support the Canadian Obesity Network)
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Saturday, May 7, 2011
That’s interesting and those do sound like high incidences of abuse, but once again, the statistics are out of context. The most obvious missing data are the baseline statistics. What percentage of people in the general population have a history of each of those types of abuse? Maybe you’re already aware of those statistics, but most people – even most medical professionals – probably aren’t. Also, where did they get the obese and binge-eating study participants? Were they representative, or were they clinical populations?
Sunday, May 8, 2011
Dr. Sharma – I was intrigued by an article “Contagious Habits: How Obesity Spreads” written by Jonah Lehrer, a neuroscientist in his blog on http://www.wired.com/wiredscience/2011/04/how-habits-spread/ In it he cites the following papers:
The Spread of Obesity in a Large Social Network over 32 Years
Nicholas A. Christakis, M.D., Ph.D., M.P.H., and James H. Fowler, Ph.D.
N Engl J Med 2007; 357:370-379July 26, 2007
Thursday Aug 20 2009 12:19 PM jcr, v36n6, 360602, BBS
I’ll Have What She’s Having: Effects of
Social Inﬂuence and Body Type on the
Food Choices of Others
BRENT MCFERRAN, DARREN W. DAHL, CAVAN J. FITZSIMONS, ANDREA C. MORALES*
Also very curious about a comment posted by a reader of this blog about rhinovirus:
“Recent research correlates obesity very strongly with antibodies to a particular rhinovirus. Catch this particular cold, and gain weight. Epidemics also follow association. How much of the shared obesity arises from psychological universals, vs. how much from infection, seems hard to tease out. Infection could render one more susceptible to the psychological effect.”
What do you think about this?
Monday, May 9, 2011
Dr. Sharma, please stick with what you know (whatever that is). You are not a trauma specialist, as I am, and you clearly have just enough knowledge of trauma to be dangerous. It looks to me like you’ve basically just paraphrased the DSM in citing the symptoms. Do you understand how the DSM works?
Please cite your study for the high prevalence of overweight and obesity in people with PTSD.
How, exactly, do you plan to “monitor patients with a history of abuse for recurrence of emotions or memories” as they lose weight? This is one of the hardest tasks an experienced trauma therapist faces, with both theoretical nuances and technical difficulties. Doing it badly can be exponentially more harmful than not doing it at all.
People with PTSD, and definitely including those with many adverse childhood experiences, develop coping mechanisms to survive. These defenses then may prove maladaptive in later relationships and in achieving career and other goals. But helping these patients to change is meticulous work that involves creating a safe environment and then deconstructing the old defenses, and then (while still maintaining that safe environment for somebody who has just let go of her sense of self and even reality in a trusting attempt to find a better world) helping them to create their own new identity and defenses out of stuff that will work well for them in the larger world.
I assume you know how to do this?
Given that dissociation is a common coping mechanism for people with PTSD, what makes you think that your discussion of “weight loss distress” at the onset of your treatment really covers all the bases? Do you know how to assess for dissociation? Do you have any idea how to manage it? Do you have any idea what happens when that management goes bad?
Do you understand how important the relationship between a trauma expert and the patient is to all of the above? I’m not talking about being a nice caring person, I mean managing a real relationship that you are having with somebody while they are going thru turbulent emotional and cognitive changes. It’s not easy for either party, and therapists who venture in without understanding what they are doing have encountered many adverse experiences of their own, including loss of license to practice. This happens to people who are well trained in trauma; it happens to good therapists.
Sure you want to wake up this dragon?
Monday, May 9, 2011
@Dr.Binks “Dr. Sharma, please stick with what you know (whatever that is)”
Thanks for this very entertaining comment, the psychiatrists (specialising in trauma) and psychologists in my team had a hearty laugh – one commented that I should also no longer diagnose diabetes because I am not a diabetologist, another suggested I should stop asking my patients whether they have experienced chest pain, because I am clearly not a cardiologist or heart surgeon. Another colleague suggested that I should perhaps refuse to sign death certificates bcause, after all I am clearly not a pathologist.
Fortunately, I don’t have to have any of those qualifications, as I can confidently pass any patients who I suspect to have any of these issues to highly qualified and specialised colleagues on my team. I fully trust that the bariatric psychiatrists, clinical psychologists, occupational therapists, physios, nurses, endocrinologists, nurses, dietitians, sleep experts, GI docs, family physicians, and surgeons who manage the patients at our centre will stick with what they know (whatever that is) and hopefully help the odd pateints who shows up in our clinic.
Tuesday, May 10, 2011
I like the fact that you posted this, but I’m made uncomfortable by some of the same things that others have noted.
I think it’s important to acknowledge that you are in a unique position compared to most physicians who will be trying to help obese patients in that you _do_ have a readily available team to pass referrals to when you are working with obese clients with a known history of abuse, maltreatment, trauma (I’d suggest adding neglect – speaking of kinds of maltreatment that affect self esteem) and consquent struggles with memories and other kinds of “triggers” that arise.
What happens then for the physician in private practice, with no team, who has a limited amount of time and sees the client less frequently than for example the client’s therapist would, and who opens him or her self up to hearing about the trauma the client has endured? I wouldn’t assume all physicians will even be comfortable with hearing about it or feel they have the time to dedicate to it – even amongst therapists some choose to specialize in work with people with known trauma and others very consciously focus their work in other areas – but hopefully know when to refer on.
I would love to see you recommend to physicians who are not in clinics such as yours that referring out, to therapists with trauma specialties is an important and helpful thing for both doctor and patient. This doesn’t mean the physician doesn’t acknowledge the importance of dealing with aftereffects of trauma, only that there’s a clearer distinction between talking about it briefly as it comes up in the medical appointments versus having a place to deal with it in more depth and intensity over time, as it affects any and every aspect of the person’s life and experience that they are able/willing to explore.
Just a few thoughts to add to the thread.
Tuesday, May 10, 2011
The first comment made in regards to this blog reminded me of a good quote: “He uses statistics as a drunken man uses lamp posts; for support rather than illumination” ~ Andrew Lang.
Thursday, May 12, 2011
I am a patient of the weight wise clinic and I am thankful to Dr. sharma for speaking aobut this . On one of my first assessment appt. with the psychologist it was clearly apparent that I had suffered from a great deal of trauma that despite hospitalizations and psychiatrist and medication I had not found healing help. Dr. sharmas explained that I needed to seek therapy first before we spoke aobut surgery. I was given a resource list with psychologist, psychiatrists, groups and many other things. The psychologists listed were people with a great deal of expertise in eating disorders and trauma. I am almost 2 years post surgery now and waited almost 2 years before having surgery. Surgery is just one tool in my tool kit. I still continue with therapy weekly and if it were not for this tool I would not have reached the place where I am today. Many people who struggle with weight have very many different reasons and complexities. It certainly is not all about food. It is far more about the brain. But forgive me I am no expert I have just lived with my struggle and disease for 52 years and although I am not totally recovered I am in recovery and becoming healthier and actually have a life. I am grateful for the point of recognition and being seen and heard and ecouraged to get the right help becuase I have been shut down by so many health care professional that I stopped talking and trusting.
Thank you. The clinic isn’t perfect but I’m not either .